The prevailing U.S. healthcare system has a number of characteristics that negatively impact healthcare communication and limit opportunities for relationship and trust building among patients and clinicians. See, e.g., American Hospital Association, “Eye on Patients: A report from the American Hospital Association and the Picker Institute”, 1997; Committee on Quality Health Care in America, “Crossing the Quality Chasm: A New Health System for the 21st Century”, National Academy Press 2001. As a result of significant time constraints and competing demands, healthcare providers are often perceived as being rushed and impersonal by their patients. Information exchange among patients' healthcare providers can be fragmented because of lack of integrated information systems, e.g. according to a 2009 Center for Disease Control (CDC) national mail survey, a minority of physicians (43.9%) reported using full or partial electronic medical record/electronic health record systems (not including systems solely for billing) in their office-based practices. Only 20.5% reported having systems that met the criteria of a basic system, and only 6.3% reported having a fully functional system, a subset of a basic system. Hsiao et al., “Electronic Medical Record/Electronic Health Record Use by Office-based Physicians: United States, 2008 and Preliminary 2009” National Center for Health Statistics, Centers for Disease Control 2009.
While technological advances undoubtedly improve medical care, such advances can undermine the quality of patient-provider communication. Increasing clinician emphasis on imaging, laboratory tests, and procedures can move the patient-provider dialogue away from patients' day-to-day issues in managing illness and toward an emphasis on solutions that are biomedical and procedure-based. Furthermore, with increased inclusion of computers in busy medical offices, patients complain that clinicians' eyes are increasingly averted away from them and toward computer screens. Linder et al., “Barriers to electronic health record use during patient visits”, AMIA Annual Symposium Proceedings, 2006, pages 499-503.
Even under ideal conditions, healthcare providers and patients may fundamentally see medical issues from different perspectives, for example as outlined in the table below.
TABLE 1Differences in communication foci between patients and healthcare providers (e.g. doctors): Patients' day-to-day experiences with symptoms and management of chronic conditions often contrasts with the biomedical view of a doctor.PATIENT (LIVES)DOCTOR (WORKS)EXPERIENTIALDIAGNOSTICDAY-TO-DAYSNAPSHOT VIEWPATIENT'S EXPLANATORY DOCTOR'S MEDICAL MODELMODELSYMPTOMSSIGNS/TEST RESULTSFUNCTION/QUALITY OF LIFEMEDICAL OUTCOME
Even greater divergence may potentially take place once a diagnosis is established and treatment is under way. At initial diagnosis, patients predominantly have questions about the type of condition (“what”) and cause (“why”) which biomedically trained healthcare providers are able to respond to, for example as illustrated in CHART 1 and CHART 2 in FIG. 22.
After an established diagnosis, however, patients' focus is more often on day-to-day management (“how”, “where”, “when”, “who”) than on the pathophysiological explanations of the condition. Healthcare providers are often less effective at answering these questions, as illustrated CHART 3 and CHART 4 in FIG. 22.
The lack of collaboration between patients and physicians has also been demonstrated in research involving analysis of audio taped healthcare visits that shows that physicians' patterns of practice can significantly limit mutual exchange. In two separate studies it was shown that at the start of a health visit, physicians interrupt patients and begin to control the content and direction of the appointment within 18 to 23 seconds, on average. Marvel et al., “Soliciting the patient's agenda: have we improved?” JAMA 1999, 281(3): pages 283-287; Beckman et al., “The effect of physician behavior on the collection of data”, Ann. Intern. Med. 1984, vol. 101, pages 692-696. Lack of collaboration and inattention to communication quality or consideration of how patients best learn and retain information contribute to poor patient recall of medical recommendations. In a study of 2600 patient-provider dyads where health visits were observed and patients were interviewed immediately after the visit, it was shown that patients recall only 50% of medical recommendations at the time of exit interviews. Flocke et al., “Direct observation and patient recall of health behavior advice” Prev. Med. 2004, 38(3): pages 343-349.
Health professionals find it increasingly hard to communicate in the way that they and their patients would like. In a recent survey of doctors in the US, ‘patient relationships’ ranked highest on the list of things doctors find most satisfying about medicine, yet only one third of surveyed doctors reported having enough time to fully communicate with and treat their patients. The Physicians' Foundation, “The Physicians' Perspective: Medical Practice in 2008”, 2008. Meaningful face-to-face time between patient and doctor has been whittled away by paperwork and administrative tasks, and the complexity of treating co-existing conditions requires that more time is spent gathering data and test results, leaving less time to hear peoples' stories and develop meaningful relationships.
These healthcare system limitations and practice patterns exist at a time when—with an aging population—there are proportionately greater numbers of patients with chronic conditions than ever before. Currently, 130 million individuals in the U.S. have at least one chronic condition and 75 million Americans have 2 or more chronic conditions. Anderson, “Chronic Conditions: Making the case for ongoing care”, Johns Hopkins University 2007. Compared to treatment of acute conditions, chronic conditions require greater emphasis on patient-provider collaboration, more education of patients about their conditions, increased preparation for visits, and greater active participation by patients and their family members. Healthcare visit length has not increased in proportion with the time required for patients and providers to managing multiple chronic conditions. In fact, the Centers for Disease Control estimates that the average length of a primary care visit in the U.S. is approximately 20 minutes, of which a only portion is effective face-to-face time. Schapert et al., “Ambulatory Medical Care Utilization Estimates for 2006” National Center for Health Statistics, Centers for Disease Control 2006.
Taking steps to improve the level of communication between patient and provider is a worthwhile effort. In addition to leading to improved patient satisfaction, there is abundant research showing that increased quality of patient-provider communication is associated with better outcomes. For example, across illnesses, treatment adherence and outcomes improve when patients are empowered, experience enhanced emotional patient-provider exchanges, sense they are equal partners with providers, perceive providers as empathic, negotiate around treatments, and actively communicate with providers. See Anderson, “Patient empowerment and the traditional medical model: A case of irreconcilable differences?” Diabetes Care 1995, vol. 18(3), pages 412-415; DiMatteo et al., “Physicians' characteristics influence patients' adherence to medical treatment: results from the Medical Outcomes Study”, Health Psychol. 1993, vol. 12(2), pages 93-102; Haszen-Kelmens et al., “Doctor-patient interactions, patients' health behavior and effects of treatment”, Soc. Sci. and Med. 1984 vol. 19, pages 19-28; Squier, “A model of empathic understanding and adherence to treatment regimens in practitioner-patient relationships” Soc. Sci. Med. 1990 vol. 30(3) pages 325-339; Wilson, “Promoting compliance: the patient-provider partnership”, Adv. Ren. Replace Ther. 1995, vol. 2(3), pages 199-206; Hall et al., “Meta-analysis of correlates of provider behavior in medical encounters”, Med. Care 1988, vol. 26(7), pages 657-675; Daltroy et al., “Doctor-patient communication and adherence to arthritis treatments”, Arthritis Care Res. 1992, 5:S19.
Conversely, poor patient-provider communication is associated with lower treatment adherence, lower satisfaction with care, greater health plan disenrollment, greater provider switching, and greater malpractice risk. See Tessler et al., “Factors affecting the choice between prepaid group practice and alternative insurance programs” Milbank Mem. Fund Q. Health Soc. 1975, vol. 53(2), pages 149-172; Ware et al., “Behavioral consequences of consumer dissatisfaction with medical care”, Eval. Program Plann. 1983, vol. 6(3-4), pages 291-298; Levinson et al., “Physician-patient communication: The relationship with malpractice claims among primary care physicians and surgeons”, JAMA 1997, vol. 277(7), pages 553-559.
Higher quality patient-provider interactions are associated with better disease self-management efforts, better treatment adherence, and improved control of glucose, lipids and blood pressure, as demonstrated through controlled trial evidence. See Anderson et al. “Health-care communication and selected psychosocial correlates of adherence in diabetes management.” Diabetes Care 1990; vol. 13, pages 66-76; Stewart et al. “Interpersonal processes of care in diverse populations”, Milbank Q. 1999, vol. 77(3), pages 305-339; Roter et al. “Effectiveness of interventions to improve patient compliance: a meta-analysis”, Med. Care 1998, vol. 36(8), pages 1138-1161; Kaplan et al. “Assessing the effects of physician-patient interactions on the outcomes of chronic disease”, Med. Care 1989, vol. 27(3 Suppl), pages 5110-127 (hereinafter Kaplan); Golin et al. “The role of patient participation in the doctor visit. Implications for adherence to diabetes care”, Diabetes Care 1996, vol. 19(10), pages 1153-1164; Glasgow et al. “Report of the health care delivery work group: behavioral research related to the establishment of a chronic disease model for diabetes care”, Diabetes Care 2001, vol. 24(1), pages 124-130; Heisler et al. “The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management”, J. Gen. Intern. Med. 2002, vol. 17(4), pages 243-252; Piette et al. “Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population”, J. Gen. Intern. Med. 2003, vol. 18(8), pages 624-633; Sherbourne et al. “Antecedents of adherence to medical recommendations: results from the Medical Outcomes Study”, J. Behav. Med. 1992, vol. 15(5), pages 447-468; Olivarius et al. “Randomised controlled trial of structured personal care of type 2 diabetes mellitus”, BMJ 2001, vol. 323(7319), pages 970-975.
Specific use of point-of-service prompt sheets (i.e. where a patient's questions are prepared and conveyed during the healthcare visit and where healthcare provider and patient both engage in using the prompt sheet) has been shown to be associated with increased recall, decreased patient anxiety, potential decrease in length of visit and improved metabolic control. See Kaplan, cited above; Brown et al., “Promoting patient participation and shortening cancer consultations: a randomised trial”, Br. J. Cancer. 2001, vol. 85(9), pages 1273-1279.